Radical Nephrectomy, Partial Nephrectomy, Nephroureterectomy, or Adrenalectomy
These four operations have in common:
- Similar disease processes necessitating an operation
- Common location of the organs involved
- Similarities in the operation itself
- Similar post-operative courses and recovery times
Radical or total nephrectomy is the surgical removal of the kidney through an incision in the flank (side of the abdomen) or abdomen. Almost all nephrectomies are performed for a diagnosis of kidney cancer (renal cell carcinoma or adenocarcinoma), although there are instances in which other diagnoses necessitate removal of a kidney (certain benign tumors, infectious/inflammatory processes, and large stones). Depending on variations in the procedure, the extent of the cancer, and an individual's particular anatomy, this operation can range from two to several more hours. There are instances in which only the area of the suspected tumor, a part of the kidney, or even half of the kidney is removed instead of taking out the entire organ. As a group these are called "partial" nephrectomy operations. This operation might be preferred in patients that have smaller tumors or tumors near the periphery(outer edge). Other reasons to attempt, or successfully perform a partial nephrectomy would be in patients with only one kidney or in patients that have illnesses that may affect the function of the remaining kidney (diabetes, long-standing hypertension, atherosclerosis, any of the primary kidney diseases, etc.). In this instance, it may be advantageous to the patient to preserve as much functioning kidney tissue as possible. We will have already discussed what we believe is most appropriate in your particular case. As discussed, there are instances in which we may initially intend to only remove part of the kidney but realize (during the operation) that total nephrectomy is necessary.
While far less common, the kidney may need to be removed because a type of bladder cancer(transitional cell carcinoma) grows in the middle of the kidney or in the upper portion of the ureter (the tube connecting the kidney with the bladder). In this operation(nephroureterectomy), both the kidney and the ureter must be removed. This operation may be commonly performed through two incisions; one in the flank and a second smaller incision in the lower abdominal region, or through one larger incision.
There is a small organ called the "adrenal gland" that sits on top of each kidney. It produces certain hormones and other chemicals in the body. In instances where the kidney tumor is very large, at the upper portion of the kidney, or where it is difficult to safely separate the two, the adrenal gland may be removed as well during this operation. Because there are two adrenal glands (like two kidneys) you can easily function with one removed. Tumors may also arise from the adrenal gland itself and thus require its removal (adrenalectomy).
Sometimes these tumors are benign (not cancer), but they are termed active (secreting too much of a hormone or chemical that results in illness) and therefore need to be removed.
The incision can be through the flank area, through the abdomen, but also may be a bit higher and through the chest wall (thoracoabdominal approach). The preparation, post-operative period, recovery time and associated complications very closely reflect those of nephrectomy.
People always ask, "Can I live with only one kidney?" The answer is yes. If your other kidney is healthy, there is no change in your lifestyle or longevity because you have lost a kidney. There are many thousands of people born with only one kidney. In patients that have chronic illnesses that may affect kidney function (diabetes, poorly controlled hypertension, atherosclerosis, any of the primary kidney diseases), we might be more cautious about close surveillance of the one remaining kidney after a nephrectomy.
Nephrectomy sometimes entails removal of lymph nodes (special glands to which the kidneys drain that filter cancer cells) in the kidney fossa. If the lymph nodes are positive (contain cancer), the operation may not be curative and other treatments may be required. In certain instances (that we have discussed in your prior consultation) if it is obvious during the operation that the nodes contain cancer, then we may elect to not complete the operation and leave the kidney intact. On the contrary, when the tumor in the kidney is large and consequently causing problems (i.e. severe blood in the urine, pain in the flank or abdomen, blockage of the kidney, compression on adjacent structures such as the liver, colon or small intestine, etc.), we might remove the kidney regardless for what we term "local control of the cancer." To reiterate, there are instances that we may suggest this operation even when we know that there is a high likelihood that the cancer has already begun to spread beyond the kidney.
Nephrectomy, nephroureterectomy or adrenalectomy can be difficult operations. Because anesthesia time may be prolonged, we may send you for an updated general physical and note of "medical clearance" from your primary physician. This is precautionary and for your own protection.
It is necessary, as with any procedure or operation requiring anesthesia, that you have not eaten for at least eight hours prior to the scheduled time. We may ask you to clean out your small intestine and colon the night before. An empty gastrointestinal tract facilitates the surgery and may also make you far more comfortable in the post-operative period.
You should plan a light lunch and early, light dinner the day prior. At 6-7:00 p.m., you will take a laxative. For the remainder of the evening, it is important to continue to drink plenty of clear fluids, but you CANNOT eat. You may drink up until midnight but not after and not in the morning of your scheduled surgery. Not all patients will be asked to take a laxative.
If you are on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. The procedure will not be performed if you are currently taking, or have recently taken any medication that may interfere with your ability to clot your blood ("blood thinners, aspirin, anti-inflammatory medicines, etc."). The most common of these medications are aspirin and all related pain relievers or anti-inflammatory compounds (whether prescription or over-the-counter). Please refer to the attached list and tell us if you took any of these within the past 10 days.
If your new medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed all of your current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.
Often today, removal of the kidney and/or adrenal gland is done with laparoscopic surgery. Laparoscopic surgery is a technique of putting a camera and surgical instruments into the body through small holes and performing the operation on a television screen. Hand-assisted laparoscopy is similar except that one hand is placed in the body through a tight fitting hole. If this is going to be done, you will receive a separate supplement section on laparoscopic surgery. We will have discussed the advantages and disadvantages of laparoscopic surgery versus open surgery with you.
For open surgery, your position on the table will depend on the surgeon's approach but maybe a "flank or decubitus position" (lying on your side) for a nephrectomy, adrenalectomy, or the first portion of a nephroureterectomy. In the nephroureterectomy, we may change you to the supine (on your back) position for the second portion of the operation if two incisions are to be used. As mentioned, the nephrectomy or adrenalectomy is sometimes performed in the supine position or what we term the "oblique position" (midway between being on your side and being on your back) depending on the approach. The type of anesthesia used will reflect the suggestion of the anesthesiologist as well as contributions from your preferences as well as that of your surgeon. General anesthesia (complete sleep) is used in almost every case, but a spinal might be acceptable in select, rare circumstances.
When this operation is performed through the flank, it is often necessary to remove the last(12th) rib or the second to last (llth) rib to allow better and safer access to the kidney or adrenal gland. You are unlikely to know that it is missing and need not worry. The first part of the operation involves mobilization (freeing the kidney from the surrounding tissues) of the kidney and identification of the ureter. During this process, we will decide whether the kidney is removable (in most instances it is) and whether there is "obvious" evidence of tumor spread. Our decision to proceed with the remainder of the surgery will depend on these findings. We then isolate blood vessels that supply the kidney (or adrenal in those cases) and tie and divide them. Lastly, the ureter is divided and the kidney is removed. In instances of nephroureterectomy using two incisions, you would be repositioned after the first incision is closed and a second incision would be made to remove the rest of the ureter down to the urinary bladder. Drains (tubes) may be placed which will remain for a few days. A catheter is placed in the urethra which will remain for a few days to keep your bladder empty.
After the procedure, you will be in the recovery room until you are ready to be moved to a regular room. If you have a significant medical history or if your surgery was longer than anticipated, we may elect to admit you to an intensive care unit for closer monitoring.
Your urine will be coming out through a catheter and emptying into a bag. The urine may be crystal clear or appear slightly bloody for a few days. Both are normal findings. You may have drainage tubes (unlikely in total nephrectomy or adrenalectomy, but common with partial nephrectomy) attached to bags to empty the excess fluid accumulation in the body from the operation. You may also have boots on your legs that inflate and deflate (intermittent squeezing) to prevent the formation of blood clots in your veins (deep vein thrombosis orDVT).
*In some instances, there may be a drainage tube or "chest tube" in the lower side of your lung cavity. In operations that require high dissection near the lung (some adrenal tumors, large kidney tumors, or upper kidney tumors/inflammatory processes in which the mass is adherent to the lung cavity), we may enter the lung cavity.
All that is required is a "chest tube" for a few days to allow the cavity to heal.
A typical hospital stay for these operations is usually less than a week depending on your particular health status and your post-operative hospital course. It is important to get out of bed either the first or second morning and spend some time in the chair. With assistance from a nurse or family member, you may walk on the first day. Drains or catheters will be removed as your surgeon sees appropriate. Upon discharge, you may have no dressing (bandage) on your incision. You will be discharged with instructions for follow-up in our office. Other than your regular medications, you may be on an antibiotic, a pain medication, and a stool softener so that you do not strain to have bowel movements. Other medications are rarely necessary but depend on your particular needs.
Expectations of Outcome
It is normal to feel a bit tired or weak for several weeks. *Remember, you had a big operation. We typically tell patients that they will be out of work for at least 4-6 weeks (up to12 weeks is possible if your occupation requires strenuous activity) and that it may take several more weeks before you truly feel like yourself.
While we will be able to tell you about our findings during surgery, you must understand that the specimen will be evaluated by the pathologists. They carefully examine the kidney and tumor area under the microscope. It may take one week before we have an official report to discuss with you. Of course you will be anxious, but we encourage you to be as patient as possible. Use that week to concentrate on your recovery.
*When imaging studies demonstrate a solid mass in the kidney that enhances (lights up)with dye injection, there is an approximately 90% chance that there is a cancer in the abnormal area. You should understand that there is a small (perhaps 10%) chance of undergoing a radical nephrectomy and subsequently being told that there is "no" cancer in the specimen. Leaving a kidney in the body that has cancer is far more of a danger than removing a kidney that has no cancer.
Possible Complications of the Procedure
ALL surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. Aside from anesthesia complications, it is important that every patient be made aware of all possible outcomes which may include, but are not limited to:
- Blood Loss/Transfusion: There is always some blood loss expected. In some instances, blood loss necessitates a transfusion. This is more common with very large tumors, tumors that are close to the large vessels in your abdomen, or with operations done for inflammatory of infectious kidneys where adhesions (scarring) are present.
- Urinary Tract Infection or Urosepsis: Although we may give you antibiotics, it is still possible for you to get an infection. It may be a simple bladder infection that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate. They will usually resolve with a few days of antibiotics. If the infection enters the bloodstream, you might feel very ill. This type of infection can present with both urinary symptoms and any combination of the following: fevers, shaking chills, weakness or dizziness, nausea and vomiting. You may require a short hospitalization for intravenous antibiotics, fluids, and observation. This problem is more common in diabetics, patients on long-term steroids, or patients with disorders of the immune system. *If you have symptoms suggesting any of the above after your discharge from the hospital, you must contact us immediately or go to the nearest emergency room.
- Wound Infection: As with any incision, an infection can occur. This would present with redness, swelling, and/or drainage (white to yellow thick fluid) from in between the sutures. Usually, these are managed with antibiotics and local wound care. In some instances, an area of the superficial (upper layer) incision needs to be opened for adequate drainage. An abscess is an infection collection in the body. It can present with the same symptoms as sepsis usually requires drainage.
- Pneumothorax (Collapse of the Lung): As discussed prior, entering the lung cavity may be done during any of these operations. A chest tube (lung cavity drain) would be placed that will be removed in 1-3 days. There are almost never long-term complications as a result.
- Urine Leak: This complication only can occur in patients who undergo a "partial" nephrectomy. When the kidney is divided to remove just the tumor (just part of the kidney), the inside is exposed. This is where urine is produced. Although this is closed, sometimes there may be persistent leakage of urine. This is why we usually leave a drain in this area after partial nephrectomies. While most of these leaks stop with time and drainage, a few could require additional minimally-invasive procedures or other operations. This complication can present immediately (while in the hospital) or even weeks later.
- Renal Infarction: Again, this complication is unique to "partial nephrectomy" operations. When we excise part or half of a kidney, we do so with careful attention to the blood supply of the remaining portion of the kidney. Sometimes this blood supply proves to be inadequate and the remaining portion of the kidney does not survive. This can also happen as a result of surgical maneuvers used to control bleeding while only removing a portion of the kidney.
- Ileus or Bowel Obstruction: Because we operate near the intestines, they can go into prolonged spasm (ileus), or they may become blocked (obstruction). Treatment ranges from observation to less commonly, surgery.
- Deep Vein Thrombosis (DVT)/Pulmonary Embolus (PE): In any operation(especially longer operations), you can develop a clot in a vein of your leg (DVT).Typically, this presents 2-7 days (or longer) after the procedure as pain, swelling, and tenderness to touch in the lower leg (calf). Your ankle and foot can become swollen. If you notice these signs, you should go directly to an emergency room and also call our office. Although less likely, this blood clot can move through the veins and block off part of the lung (PE). This would present as shortness of breath and possibly chest pain. We may sometimes ask the medical doctors to be involved with the management of either of these problems.
- Injury to the Small Intestine or Colon: The kidneys lie in close proximity to portions of the small intestine and the colon. Local extension of the cancer or inflammation may make it difficult to separate the two. Intestinal or colon injuries are a rare occurrence and can often be repaired immediately at the time of their recognition. It is uncommon to need a major procedure such as a temporary colostomy (bag for stool). A general surgeon is sometimes asked to assist with this problem.
- Liver (Hepatic) or Spleen (Splenic) Injury: Very large tumors or those associated with adhesions (scarring and inflammation) can sometimes be attached to surrounding organs: On the right, the liver, and on the left, the spleen. In an attempt to separate the two, either organ can be injured. The injury is usually small and is easily repaired. A significant injury may require a blood transfusion. Less commonly, part of all of an organ may need to be removed. A general surgeon may be asked to assist with this problem.
- Inability to Remove the Kidney: Although quite unusual, a patient's anatomy, excessive bleeding, local spread of the cancer, or inflammation and adherence to adjacent organs may prohibit the surgeon from safely removing the kidney or adrenal.
- Hernia: When we close a flank incision, we pay careful attention to the various layers of muscle and fascia (tissue lining the muscle). Nevertheless, this area is prone to develop hernias (weakness or bulging). This is usually a cosmetic issue only, but other times requires repair.
- Chronic Pain: While unusual, any patient can develop chronic pain in an area that was subject to surgery. The cause is not always forthcoming. While this usually resolves with time, consultation with a pain specialist may be necessary.
- Death: The incidence of death during or shortly after the operation is approximately1% or less. It is usually a result of an unexpected cardiac (heart) event or a pulmonary(lung) event. We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).
The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While Delta Medix endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. Delta Medix cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.
Delta Medix, P.C.